State Epidemiologist’s Standing Order for COVID-19 Testing

STATE OF MAINE DEPARTMENT OF PROFESSIONAL AND FINANCIAL REGULATION BUREAU OF INSURANCE 34 STATE HOUSE STATION AUGUSTA, MAINE 04333-0034 Janet T. Mills Governor Eric A. Cioppa Superintendent PRINTED ON RECYCLED PAPER O F F IC E S L O C A T ED A T 76 N O R T H ER N AV EN U E, G A R D IN ER, M AI N E 04345 www.maine.gov/insurance Phone: (207) 624-8475 TTY: Please call Maine Relay 711 Consumer Assistance: 1-800-300-5000 Fax (207) 624-8599 Bulletin 450 State Epidemiologist’s Standing Order for COVID-19 Testing On March 12, 2020, under the powers granted by the Governor’s emergency proclamation, I issued an order directing all carriers offering health plans subject to the Maine Health Plan Improvement Act, as defined at 24-A M.R.S. § 4301-A(7), to make medically necessary screening and testing for COVID-19 available with no deductible, copayment, or other cost sharing of any kind, including all associated costs such as processing fees and clinical evaluations. Carriers may not make first-dollar coverage under that order dependent on any prior authorization requirement, and may not make first-dollar coverage dependent on the use of network providers unless the enrollee is offered the service in-network without additional delay but chooses instead to visit an out-ofnetwork provider or to be tested by an out-of-network laboratory. The State Epidemiologist, Siiri Bennett, M.D., issued a Standing Order on June 8, 2020, authorizing health care providers and other designated trained personnel to conduct SARS-CoV-2 molecular testing on anyone meeting one or more of the risk criteria described in the order, and further authorizing the laboratory analysis of test specimens and reporting of test results. I am issuing this Bulletin to clarify that services performed under the authorization of the Standing Order, for persons described within Categories A (known exposure) and B (elevated risk factors), are considered “medically necessary” within the meaning of the Health Plan Improvement Act, and as such, are eligible for first-dollar coverage under the terms of my March 12 order. The Insurance Code defines “medically necessary health care” to mean: health care services or products provided to an enrollee for the purpose of preventing, diagnosing or treating an illness, injury or disease or the symptoms of an illness, injury or disease in a manner that is: A. Consistent with generally accepted standards of medical practice; B. Clinically appropriate in terms of type, frequency, extent, site and duration; C. Demonstrated through scientific evidence to be effective in improving health outcomes; D. Representative of “best practices” in the medical profession; and E. Not primarily for the convenience of the enrollee or physician or other health care practitioner.1 The testing described within Categories A and B of the Standing Order is conducted “for the purpose of preventing [or] diagnosing ... an illness,” COVID-19, in the person being tested, and the Standing Order embodies Dr. Bennett’s clinical judgment and official determination that the five clinical criteria of the statutory definition are satisfied. Therefore, testing conducted under those categories meets the medical necessity criteria for first-dollar coverage under my March 12 order. June 18, 2020 Eric A. Cioppa Superintendent of Insurance NOTE: This Bulletin is intended solely for informational purposes. It is not intended to set forth legal rights, duties, or privileges, nor is it intended to provide legal advice. Readers should consult applicable statutes and rules and contact the Bureau of Insurance if additional information is needed. 1 24-A M.R.S. § 4301-A(10-A).